Cardiac MR -Complimentary -Competitor...
Transcript of Cardiac MR -Complimentary -Competitor...
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Cardiac MR -Complimentary -Competitor -Conqueror ?
Dr Girish Dwivedi MRCP (UK), PhD (UK), FASE
Staff Cardiologist, Assistant Professor in Medicine
University of Ottawa Heart Institute
University of Ottawa, Canada
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Today’s talk
Physics
Indications and Examples
Safety
Questions
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Nishimura DG. Principles of MRI. & Lawson Imaging 3-T facility, Siemens Verio
Body lies on table encompassed by coils for
static field (Bo), gradient fields (Gz and Gx
shown), and radiofrequency field (RF or B1).
Physics
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Which is likely to result in most harm or damage?
A. Putting a patient with mechanical valves and sternal wires in MRI.
B. Putting a patient with reveal device, stents or ASD occluder in MRI.
C. Putting a patient with Pacemaker in MRI.
D. Putting a patient with intracranial clip in MRI.
E. Returning home late after finishing consults and forgetting your sigmificant others birthday.
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MRI: Mapping abundance & behavior of hydrogen nuclei in tissues.
Tissues are largely water and fat
many hydrogen atoms (humans are ~ 63% hydrogen!)
Hydrogen nucleus comprised of a single proton
Each proton can be viewed as a small magnetic field
Bare H proton has a nuclear spin, and total angular momentum
Physics
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My old boss
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Difference between Iron and Steel
Ferromagnetic
Paramagnetic
Diamagnetic
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Processing
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How does it work?
T1 weighted Spin echo Gradient echo
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So where is it useful, really?
Left ventricular function
Ischaemic Heart disease – One stop
Cardiomyopathy – Dare you do it without CMR?
“Fascinomas”
Congenital heart disease
And just about every other cardiac and great vessel disease………….
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So why bother?
No dependence on acoustic windows – can “always” get good quality images
Can do things echo can’t – New perspectives on common diseases
Can pick any plane
Accurate
Reproducible
No radiation
Image quality
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It’s not all good news
Expensive
Fixed
Not real time
Cardiac/respiratory artefacts
Resolution
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Portability
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1. CMR LV function
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Base
Apex
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LV-RV stroke volumes in normal hearts
Longmore Lancet 1985; 1360-2
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Pennel, AHJ, 2002
Echo 230
CMR 28
Reduce number of subjects in trials
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2. Ischaemic heart disease
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IHD
Bulk of our work
Myocardial Ischaemia
Stress wall motion
Stress perfusion
Myocardial viability
Complications of IHD
Coronary angiography
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Hibernating myocardium
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Hibernating myocardium
Hypokinetic myocardium which has the potential to improve in function
Cellular integrity
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Late enhancement Gd
TTC MRI
R Judd, Northwestern University, Chicago
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Validation of Gadolinium Hyper enhancement in CMR
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This is something unique:
Imaging “dead” heart muscle as well as live heart muscle
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Transmural Extent of Scar and Functional Recovery
Kim R, ACC Sessions 2000
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Gadolinium
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Cine Late Gad
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Case example
83 years old
Little comorbidity
Severely limited by SOB
Severe 3 vessel disease
Severely impaired LV function.
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CMR- Pre CABG
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CMR- Post CABG
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Myocardial Perfusion
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Stress
Rest
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Coronary artery imaging
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Radiation
Ca scoring X Ray angio CT angio
Cardiac MR Echo Exercise testing
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Anomalous RCA with Inter-arterial Course
LAD
LCX
R
L NC
Pulmonary trunk
RCA
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Can it be done?
Li D. Radiology 1996; 201: 857-63.
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3 Tesla coronary MR
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But
Not robust
Not reproducible
Resolution
Technical issues
Time
Is it what we need?
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3. Cardiomyopathy
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HCM
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Apical HCM
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Case example
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Right ventricular cardiomyopathy
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ARVC
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Iron cardiomyopathy
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Before
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And after
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Congenital heart disease
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Quadricuspid Aortic Valve
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Complex ACHD
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Next Images
It’s an attempt to image the first test baby by echo and shows a normal heart
No, they represent Zebra fish embryo heart.
Actually, a resident (this time medicine) is trying image an abnormal heart.
None or all the above
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Echo: Unclear Apical views
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Congenital Heart Disease (real case)
Abdominal and atrial situs solitus, AV/VA concordance.
Malposition of the great arteries
Tricuspid atresia
Dextrocardia
Juxtaposed right atrial appendages
Acquired pulmonary atresia
Aged 6 weeks right classical Blalock-Taussig shunt
Aged 4 years left classical Blalock-Taussig shunt
Aged 7 years modified Fontan operation (SVC to right pulmonary artery,
right atrial appendage to left pulmonary artery)
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Fontan operation
Done in single ventricle circulation
Congenital cardiac malformation in which one ventricle is dormant or biventricular repair is not possible
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3D non-contrast enhanced MRI
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Mechanical valves, annuloplasty rings-OK ASD device, PFO, Duct closure etc-OK Stents: OK Pacemaker, ICD-XX Sternal wires, epicardial wires-OK Catheters if poly urethane or PVC OK LVAD and IABP-XXXX www.mrisafety.com. www.radiology.upmc.edu/MRsafety. www.IMSER.org
Guidelines for 1.5 T scanner
Safety
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Gold standard
1. Ventricular volumes
2. Ventricular function
3. Complex congenital heart disease
4. Imaging of other structural abnormalities
5. Myocardial viability
6. (aortic disease)
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On it’s way
Myocardial perfusion imaging
Coronary artery imaging?
Quantification of
Myocardial function
Scar
Perfusion
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The Future
Single examination for CAD
MR spectroscopy
Real time imaging
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Thank you